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Now what?
By Jacquelyn H. Burns, DVM
                             © Jacquelyn H. Burns 2012
                             All rights reserved
   Kidney damage that is cumulative enough to cause
       Patient to not feel as well as he or she should
         Weight loss
           A consequence of decreased appetite
             Probably due to nausea/queasiness
       Loss of function
         Production of dilute urine (lots and lots of urine!)
           Patient drinks more water to compensate for this
         Buildup of waste products in blood stream
           Gastrointestinal irritation/ulceration
             Probable cause of decreased appetite
         Anemia
   No, but patients often feel tired, queasy or
    nauseated and maybe just disinterested in life
   Acquired
       Toxins
         Anti-freeze (ethylene glycol)
         Certain toxic plants
       Recurrent untreated conditions
         Urinary tract infections/disease
         Other chronic diseases
         Glomerulonephritis
       Age-related?
         While I tell my clients “Old age is not a disease,” the majority of the
          chronic renal failure (CRF) patients are middle-aged and older. An
          insult here/an insult there, over time, can damage and scar the
          kidneys, leading to loss of function. Older pets are more likely to have
          accumulated damage causing loss of functional kidney tissue.
   Congenital
       Some breeds are more prone to it than others
   While we tell clients “Old age is not a
    disease,” the majority of the chronic
    renal failure (CRF) patients are middle-
    aged and older. An insult here/an insult
    there, over time, can damage and scar the
    kidneys, leading to loss of function.
    Older pets are more likely to have
    accumulated damage causing loss of
    functional kidney tissue.
   “Insults” can result from blood
    clots, infections, trauma, shock, to
    xins and drugs, and diseases
    affecting other organs
                                                           Guy
   Cells that are “insulted” badly                       walks
    enough die and are replaced by                        into a
    scar tissue                                           bar…
   Kidneys have an enormous
    “reserve capacity”                          I don’t
       Up to 75% of functional tissue called    get no
        nephrons can be lost and the kidneys    respect
        still manage to keep up with their
        work
       Once 76% or more of the nephrons
        are damaged, the kidneys begin to
        get behind in their work
   Toxins build up in the blood stream
       Which lead to gastrointestinal irritation
         Which cause heartburn, nausea, lethargy
           Which cause patient to eat less
             Which cause the patient to lose weight

• Kidneys can dilute the filtered
  blood, but not re-concentrate
        • Leads to dilute urine
           • Leads to drinking more/urinating larger volume
   Hypertension  retains more fluidheart has
    to work harder
   Protein loss in urine  low blood
    proteinpatient feels badpatient eats poorly
   Lack of erythropoitinanemiapatient feels
    badpatient eats poorly
   Electrolyte inbalances, ugh! Don’t get me
    started!!! High phosphorouslow calcium
   Appetite loss or disinterest in food
       Sometimes anorexia
   Weight loss
   Increased thirst/increased interest in water
       Having to fill the water bowl up more often
   Increased urine volume
       More urine volume
         Bigger puddles
         More saturated litter box/having to change more often
   Urinating in house or on bedding
   Lethargy/listlessness
   Vomiting
   Weight loss or low body condition score
   Sometimes pale mucous membranes
       Lining of eyes
       Lining of mouth
       Noses on fair-skinned pets
   Sometimes kidneys palpate abnormally
     Most often small, hard and lumpy—pitted and
      scarred
     Sometimes swollen

   Sometimes halitosis, thick saliva, oral ulcers
   Urinalysis
       Proteinuria
         Protein:Creatinine ratio test may be needed to assess.
       Low urine specific gravity
         This means the urine is very dilute
   Blood Tests
     High Creatinine and BUN (blood urea nitrogen)
     High phosphorous
     High potassium
     Anemia
         Low hematocrit
   Kidneys can be evaluated by
    various kinds of diagnostic
    imaging
       X-rays
       Ultrasound
   Renal biopsy


Though it often doesn’t
change the outcome, a
renal biopsy is the most
definitive test to assess
cause of and prognosis
for kidney disease.
???????
   Pretty simple. KD=Kidney Diet
       Low protein content=lower workload for kidneys
         Less nitrogenous waste products to be filtered out
       Increased fat content
         Fat increases calories
         Fat increases palatability!
       Reduced levels of
         Sodium
         Potassium
         Phosphorous
   Not a drug but a nutraceutical
   Contains microbes that “digest” nitrogenous
    waste products in the gastrointestinal tract
   Fewer waste products in G-I tract mean less to
    be absorbed and filtered by the kidneys
       Goal to keep Creatinine and BUN low(er)
   Special precautions
     Refrigerate
     For best results, give capsules whole
   Also a nutraceutical
   Phosphorous in the G-I tract binds to it
       Reduces absorption of phosphorous in gut
       Makes for lower phosphorous blood levels
   Made from ground up crustacean shells
       Powdered and palatable
         What cat doesn’t like the taste of shrimp and crab?
   Not added to our treatment regimen until
    phosphorous blood levels are increased
   Sucralfate, an gastro-intestinal protectant
     Binds to irritated stomach and intestinal lining
     Decreases heartburn, queasiness, nausea
   Pepcid AC, an antacid
     Reduces gastric acid secretions
     Decreases heartburn, queasiness, nausea
   Reglan, an anti-emetic
       Decreases nausea, vomiting
   Anti-hypertensives are helpful in many
    cases, particularly in patients with
    Glomerulonephritis, an inflammatory process
    that adversely affects the kidneys and causes
    protein loss via the urine
   I saved the fluids for last.
    People are often intimidated
    by the idea of administering
    fluids at home. It can be
    scary, but most people can
    learn to do it. If
    not, sometimes they bring
    the pet in 2 to 3 times
    weekly for fluid
    administration by our
    technicians
   Most often are
    prescribed for cats
   Needle is placed under
    the loose skin on the
    shoulder/neck area
   Fluids run by gravity
   Take 5 to 10 minutes to
    do
   Usually done 2 to 3
    times weekly
   Our technicians can show
    you how to do this at
    home.
   Requires:
       A bag of LRS
       An IV Line
       18 or 20 gauge hypodermic
        needles

   USE A FRESH, UNUSED
    NEEDLE EACH TIME.
    The IV line is multi-use if
    you are very clean with it.
   Regular checkups to include
    BUN, Creatinine, Phosphorous, Calcium, Sodiu
    m and Potassium
       Intervals between checkups to be determined by
        your veterinarian.
       Of these, we are most concerned with creatinine and
        phosphorous
   Numbers matter, but only insofar as the patient
    feels well. We want our pets to feel well
    enough to eat, play and love with gusto, no
    matter how low or high their creatinine is.
   This material is intended to help veterinary clients
    understand chronic kidney disease and how it
    affects their pet, as well as one veterinary practice’s
    general approach to treatment. Each patient is an
    individual and must be assessed and treated by his
    or her own veterinarian, according to that
    veterinarian's clinical judgment and that patient’s
    unique needs.
   For proper diagnosis and treatment, see your
    veterinarian. ( preferably with a cup of urine in
    your hand  )
   Jacquelyn H. Burns, DVM
   Holmes Veterinary Hospital
    1001 Church Street
    Laurens, SC 29360
    www.holmesvethospital.com

All rights reserved
Copyright © 2012 by Jacquelyn H. Burns, DVM

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My pet has chronic renal failure!

  • 1. Now what? By Jacquelyn H. Burns, DVM © Jacquelyn H. Burns 2012 All rights reserved
  • 2. Kidney damage that is cumulative enough to cause  Patient to not feel as well as he or she should  Weight loss  A consequence of decreased appetite  Probably due to nausea/queasiness  Loss of function  Production of dilute urine (lots and lots of urine!)  Patient drinks more water to compensate for this  Buildup of waste products in blood stream  Gastrointestinal irritation/ulceration  Probable cause of decreased appetite  Anemia
  • 3. No, but patients often feel tired, queasy or nauseated and maybe just disinterested in life
  • 4. Acquired  Toxins  Anti-freeze (ethylene glycol)  Certain toxic plants  Recurrent untreated conditions  Urinary tract infections/disease  Other chronic diseases  Glomerulonephritis  Age-related?  While I tell my clients “Old age is not a disease,” the majority of the chronic renal failure (CRF) patients are middle-aged and older. An insult here/an insult there, over time, can damage and scar the kidneys, leading to loss of function. Older pets are more likely to have accumulated damage causing loss of functional kidney tissue.  Congenital  Some breeds are more prone to it than others
  • 5. While we tell clients “Old age is not a disease,” the majority of the chronic renal failure (CRF) patients are middle- aged and older. An insult here/an insult there, over time, can damage and scar the kidneys, leading to loss of function. Older pets are more likely to have accumulated damage causing loss of functional kidney tissue.
  • 6. “Insults” can result from blood clots, infections, trauma, shock, to xins and drugs, and diseases affecting other organs Guy  Cells that are “insulted” badly walks enough die and are replaced by into a scar tissue bar…  Kidneys have an enormous “reserve capacity” I don’t  Up to 75% of functional tissue called get no nephrons can be lost and the kidneys respect still manage to keep up with their work  Once 76% or more of the nephrons are damaged, the kidneys begin to get behind in their work
  • 7. Toxins build up in the blood stream  Which lead to gastrointestinal irritation  Which cause heartburn, nausea, lethargy  Which cause patient to eat less  Which cause the patient to lose weight • Kidneys can dilute the filtered blood, but not re-concentrate • Leads to dilute urine • Leads to drinking more/urinating larger volume
  • 8. Hypertension  retains more fluidheart has to work harder  Protein loss in urine  low blood proteinpatient feels badpatient eats poorly  Lack of erythropoitinanemiapatient feels badpatient eats poorly  Electrolyte inbalances, ugh! Don’t get me started!!! High phosphorouslow calcium
  • 9. Appetite loss or disinterest in food  Sometimes anorexia  Weight loss  Increased thirst/increased interest in water  Having to fill the water bowl up more often  Increased urine volume  More urine volume  Bigger puddles  More saturated litter box/having to change more often  Urinating in house or on bedding  Lethargy/listlessness  Vomiting
  • 10. Weight loss or low body condition score  Sometimes pale mucous membranes  Lining of eyes  Lining of mouth  Noses on fair-skinned pets  Sometimes kidneys palpate abnormally  Most often small, hard and lumpy—pitted and scarred  Sometimes swollen  Sometimes halitosis, thick saliva, oral ulcers
  • 11. Urinalysis  Proteinuria  Protein:Creatinine ratio test may be needed to assess.  Low urine specific gravity  This means the urine is very dilute  Blood Tests  High Creatinine and BUN (blood urea nitrogen)  High phosphorous  High potassium  Anemia  Low hematocrit
  • 12. Kidneys can be evaluated by various kinds of diagnostic imaging  X-rays  Ultrasound
  • 13. Renal biopsy Though it often doesn’t change the outcome, a renal biopsy is the most definitive test to assess cause of and prognosis for kidney disease.
  • 14.
  • 16. Pretty simple. KD=Kidney Diet  Low protein content=lower workload for kidneys  Less nitrogenous waste products to be filtered out  Increased fat content  Fat increases calories  Fat increases palatability!  Reduced levels of  Sodium  Potassium  Phosphorous
  • 17. Not a drug but a nutraceutical  Contains microbes that “digest” nitrogenous waste products in the gastrointestinal tract  Fewer waste products in G-I tract mean less to be absorbed and filtered by the kidneys  Goal to keep Creatinine and BUN low(er)  Special precautions  Refrigerate  For best results, give capsules whole
  • 18. Also a nutraceutical  Phosphorous in the G-I tract binds to it  Reduces absorption of phosphorous in gut  Makes for lower phosphorous blood levels  Made from ground up crustacean shells  Powdered and palatable  What cat doesn’t like the taste of shrimp and crab?  Not added to our treatment regimen until phosphorous blood levels are increased
  • 19. Sucralfate, an gastro-intestinal protectant  Binds to irritated stomach and intestinal lining  Decreases heartburn, queasiness, nausea  Pepcid AC, an antacid  Reduces gastric acid secretions  Decreases heartburn, queasiness, nausea  Reglan, an anti-emetic  Decreases nausea, vomiting
  • 20. Anti-hypertensives are helpful in many cases, particularly in patients with Glomerulonephritis, an inflammatory process that adversely affects the kidneys and causes protein loss via the urine
  • 21. I saved the fluids for last. People are often intimidated by the idea of administering fluids at home. It can be scary, but most people can learn to do it. If not, sometimes they bring the pet in 2 to 3 times weekly for fluid administration by our technicians
  • 22. Most often are prescribed for cats  Needle is placed under the loose skin on the shoulder/neck area  Fluids run by gravity  Take 5 to 10 minutes to do  Usually done 2 to 3 times weekly
  • 23. Our technicians can show you how to do this at home.  Requires:  A bag of LRS  An IV Line  18 or 20 gauge hypodermic needles  USE A FRESH, UNUSED NEEDLE EACH TIME. The IV line is multi-use if you are very clean with it.
  • 24. Regular checkups to include BUN, Creatinine, Phosphorous, Calcium, Sodiu m and Potassium  Intervals between checkups to be determined by your veterinarian.  Of these, we are most concerned with creatinine and phosphorous  Numbers matter, but only insofar as the patient feels well. We want our pets to feel well enough to eat, play and love with gusto, no matter how low or high their creatinine is.
  • 25. This material is intended to help veterinary clients understand chronic kidney disease and how it affects their pet, as well as one veterinary practice’s general approach to treatment. Each patient is an individual and must be assessed and treated by his or her own veterinarian, according to that veterinarian's clinical judgment and that patient’s unique needs.  For proper diagnosis and treatment, see your veterinarian. ( preferably with a cup of urine in your hand  )
  • 26. Jacquelyn H. Burns, DVM  Holmes Veterinary Hospital 1001 Church Street Laurens, SC 29360 www.holmesvethospital.com All rights reserved Copyright © 2012 by Jacquelyn H. Burns, DVM